A study of people who used heroin in prison gives vital clues on reaching out to this significant and vulnerable cohort. Lana Durjava shares her findings.
Recent reports on drug use in prison have highlighted the increased use of new psychoactive substances; however heroin is still a significant concern and tends to be used for longer periods than other drugs such as cocaine and amphetamine. Additionally, prisoners often present with dual diagnosis and polysubstance addiction, which amplify problems associated with their wellbeing and raise concerns for staff and prison security.
Heroin use carries multiple health, legal and social implications, such as increased risk of blood-borne viruses, infections, injecting-related complications, poor health, risk of overdose, social isolation and engagement in criminal activities. In a prison setting it carries additional challenges, with individuals often engaging in riskier behaviour due to contextual factors such as unsafe environment, limited availability of harm reduction services and a climate in which they have to hide their drug use to avoid punishment for failing mandatory drug testing.
Incarceration has an overwhelming impact on everyday life. It brings multiple losses, some of which are irretrievable – loss of liberty, relationships, opportunities, time, and control over one’s own life – and heroin use is one of the means of coping with these losses. The prison environment, with its climate of hostility, suspicion and unpredictability, means regular exposure to feelings of isolation and threats of violence.
The prison population in England and Wales has doubled in the last 25 years due to increases in custodial sentencing and sentence lengths. This has resulted in a population comprising many more prisoners with mental health problems, substance use disorders and histories of self-harm and suicide attempts.
‘Heroin made me bulletproof’
A qualitative study was conducted with former prisoners who had experienced heroin addiction while inside. The aim was to gain better understanding of psychological and social aspects of the phenomenon, and to explore how to support people in this situation to achieve recovery most effectively.
Compulsive heroin use is generally the result of a number contributing factors; however all participants in the study said that one of the main purposes of their heroin use was to regulate overwhelming emotions. Heroin use was an attempt at self-regulation and management of difficult emotional states, with the ever-present theme being an attempt to disconnect from reality and achieve a state of numbness.
‘It kept my emotions stable. Constantly when I was on gear, I’d feel composed, I don’t get angry, I don’t get upset, I just deal with stuff, I feel pretty much invincible when I am on it…
‘It’s not always easy sitting in prison and thinking who’s my missus sleeping with now, who’s trying to play dad to my daughter, what does my daughter think of me, who’s driving my car… Cos you know you lose everything every time you go to prison. You don’t get a chance to sort your stuff out, you just lose everything.’ (Ben)
The conceptualisation of heroin use as an emotion regulator and coping mechanism, which people resort to because they have failed to develop adaptive responses to stress and negative emotional states, is not something new. It matches the self-medication hypothesis, which argues that a person who is more sensitive to emotional distress and who has a lower ability to self-regulate is at greater risk of progressing from experimental to dependent drug use as a means to cope. Indeed, the results of this study showed that participants used heroin to self-medicate.
Ability to self-soothe in times of distress is essential for healthy emotional functioning and to prevent the person from becoming emotionally overwhelmed. Being unable to do this is commonly connected with the problem of internalisation – not learning how to regulate emotions from a primary caregiver at an early stage, which would have allowed someone to practise effective self-care. People who are addicted to heroin have often been described as having disturbed global ego function, turning to the drug to self-regulate.
Generally speaking, a person’s choice of a particular drug is not accidental and different drugs are chosen to cope with different forms of emotional distress. With its characteristic ability to kill physical and emotional pain, heroin appears to be a magic drug, ideal for coping with the pain and loss associated with imprisonment.
‘It helped me deal with emotions I guess, I mean it helped me suppress them. It made me feel numb and that was what I needed at the time cos life was overwhelming otherwise. I felt depressed and all, but then I took heroin and did not feel anything at all. I could forget the mess I was in, I mean I lost my kids and all and I didn’t really care or feel anything about it when I was on heroin.’ (Mark)
‘It’s my obsession’
This study also aimed to explored participants’ relationship with heroin – a relationship that was characterised by obsession and ambivalence and was prioritised above individuals’ interpersonal relationships. Participants manifested a strong attachment to the drug, which was experienced as a secure base and safe haven. They perceived it as an attachment figure, gravitated towards it in times of distress and used it as a source of comfort and safety.
This tallies with previous research on attachment and heroin addiction, which argued that due to its neuro-biological properties, the drug was used to compensate for the absence of satisfying relationships. It was previously shown that heroin is chosen to serve specific emotional and social needs; so one possibility is that people who experience problems in forming close and trusting relationships gravitate towards heroin use. Later on, their heroin use can complicate interpersonal relations and so limit their potential for forming trusting relationships.
The findings suggested that heroin use has a significant impact on object relations – the need for contact with others. Relationships were made based on drugs, disproportionate power dynamics emerged between heroin users and suppliers, a climate of mistrust was created, and the participants tended to isolate themselves and maintain distance from any meaningful interpersonal contact. Prisoners with drug problems often oscillated between feelings of empowerment and disempowerment, based on their level of addiction and drug accessibility.
‘[With the other inmates] it was very basic, there was no friendship or relationship there really, it was just focused on getting and using the drugs, that was as far as it went. You were just talking about what’s happening and who has the money and who has the gear and who will score and where to use it and stuff like that.’ (Adam)
The disparity involved in the power dynamics between heroin users and dealers became particularly evident during withdrawal, when biopsychosocial discomfort induced fear and isolation. Sizeable debts could also build up among prisoners, creating additional complications – often compounded by prisoners’ mental health problems. Certainly the participants in this study reported mistrust of both the authorities and other prisoners, where heroin had the dual purpose of being both ‘a blessing and a curse’.
‘You’ve gotta deal with people who you’re buying it off and they obviously use it as an element of power… Then the obvious violence that goes with it as well, cos things don’t always run smoothly… People rob other people, nick their stuff, people don’t pay people, so it’s kinda like, yeah, looking back I don’t know how I had the energy to do it.’ (Ben)
The study aimed to contribute to the existing knowledge about the psychological and social experience of heroin addiction in prison – an experience that could be summarised as a life of lonely compulsion in a mundane and ruthless environment. While the findings cannot be generalised to the wider prison population, they nevertheless offer a fair indication of the everyday reality of people who experience heroin addiction during incarceration.
British prisons are in a state of perpetual crisis, with endemic drug use, bullying and violence being fundamental parts of daily reality. The prison system currently appears to be mostly about containment and risk management and is characterised by limited resources, staff shortages, lack of meaningful activities and support services that are inadequate in responding to prisoners’ needs.
It is hoped that, with time, an holistic approach will be more consistently adopted that addresses the multiple health, social and psychological needs of the prison population, despite all the contextual pressures and factors that hinder recovery from compulsive drug use and offending. Furthermore, it is hoped that the prison service will employ less punitive strategies in the detection and punishment of illicit drug users – and that custodial sentencing will incarcerate violent offenders, rather than those who are vulnerable, with complex needs, and deemed ‘petty’ criminals.